Study guide
25.4 Pregnancy/Post-Partum, Post-Transplant, and Pediatric Patients (03.T–U)
ABIM Neurocritical Care Subspecialty Certification Exam
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1 Introduction & Exam Overview
1.1 Current Exam Facts 1.2 Eligibility, Practice Pathway, and the IM Training Route 1.3 Format, Scoring, Pearson VUE, and Score Reports 1.4 How to Use This Independent Study Guide
2 ICU Neurologic Exam, Cerebral Physiology, and CSF
2.1 Neurological Examination in the ICU 2.2 Cerebral Physiology, ICP, CBF, and Autoregulation 2.3 CSF Physiology
3 Core Neuropharmacology
3.1 Osmotic Agents 3.2 Anti-Seizure Drugs 3.3 Anesthetics, Sedatives, Analgesia, and Paralytics 3.4 Antihypertensives, Vasopressors, and Inotropes
4 Reperfusion Drugs, Airway, and Ventilation
4.1 Thrombolytics, Anticoagulants, and Antiplatelets 4.2 Reversal of Anticoagulation After Acute Hemorrhage 4.3 Airway Management and Tracheostomy 4.4 Mechanical Ventilation
5 Hemodynamics and Shock
5.1 Hemodynamic Monitoring 5.2 IABP, Temporary VADs, LVAD, and ECMO 5.3 Diagnosis and Management of Shock
6 Nutrition, Temperature, and ICU Prophylaxis
6.1 Nutrition (01.J) 6.2 Temperature Control (01.K) 6.3 ICU Prophylaxis, Delirium, and Early Mobility (01.L)
7 General Trauma
7.1 Emergency Evaluation of Polytrauma, Chest, and Abdominal Trauma 7.2 Long-Bone Fractures and Fat Embolism 7.3 Burns, Electrical Injury, and Hanging/Strangulation
8 Pulmonary Critical Care
8.1 Pulmonary Physiology and ARDS (01.N.1–2) 8.2 PE, Pneumonia, and Pulmonary Edema (01.N.3, 7–8) 8.3 COPD, Asthma, PAH, and Bronchoscopy Basics (01.N.4–6, 9)
9 Cardiovascular Critical Care
9.1 Cardiovascular Physiology, Stress Cardiomyopathy, ACS, and Valves 9.2 Arrhythmias and Pacing 9.3 Acute Aortic Dissection and Cardiac Ultrasound
10 Renal and Infectious Disease
10.1 AKI, RRT, and Renal Drug Dosing 10.2 Acid-Base and Electrolyte Disorders 10.3 Severe Sepsis, Septic Shock, and Infective Endocarditis 10.4 Antimicrobial Use and Infection in the Immunosuppressed
11 Endocrine and Salt-Water Disorders
11.1 Pituitary Apoplexy, DI, and Panhypopituitarism (01.R.1–4) 11.2 SIADH and Cerebral Salt Wasting (01.R.5–6) 11.3 Thyrotoxicosis, Myxedema, Adrenal Crisis, and Dysglycemia (01.R.7–9)
12 Gastrointestinal Critical Care
12.1 GI Physiology, Acute Abdomen, Bleed, Ileus, and Perforation (01.S.1–5) 12.2 Mesenteric Ischemia and Abdominal Compartment Syndrome (01.S.6–7) 12.3 Fulminant Liver Failure, Cirrhosis Decompensation, and Hepatic Dosing (01.S.8–10)
13 Hematologic Disorders
13.1 Anemia, Transfusion, Thrombocytopenia, Coagulopathy, and DIC (01.T.1–4) 13.2 VTE in the Neuro ICU (01.T.5) 13.3 Chemo/Immune, SCT, CAR-T, Sickle Cell, and TMA (01.T.6–10)
14 Neuroimaging
14.1 CT of Brain and Spine 14.2 MRI and CT/MR Perfusion 14.3 Noninvasive Angiography and Catheter Angiography
15 EEG, EMG, and CSF Analysis
15.1 EEG, Standard and Processed (02.B) 15.2 Basic EMG Interpretation (02.G) 15.3 CSF Analysis (02.H)
16 ICP, TCD, and Multimodality Monitoring
16.1 ICP Monitoring (02.C) 16.2 Transcranial Doppler (02.D) 16.3 Brain-Tissue Oxygen and Multimodality Monitoring (02.E–F)
17 Brain Death and Bedside Procedures
17.1 Brain Death Prerequisites and Clinical Exam (02.I) 17.2 Apnea Testing and Ancillary Studies (02.I) 17.3 Vascular Access, Thoracic Echo, and Lung Ultrasound (02.J–L)
18 Coma, Anoxia, and Intracranial Hypertension
18.1 Coma and Other States of Altered Consciousness (03.A) 18.2 Global Anoxia-Ischemia and Post-Resuscitation Encephalopathy (03.A.1) 18.3 Toxidromes, ICU Delirium, and Hypertensive Encephalopathy (03.A.2–4) 18.4 Intracranial Hypertension as a Disease State (03.B)
19 Acute Ischemic Stroke
19.1 IV Reperfusion Therapy (03.C.3) 19.2 Mechanical Thrombectomy Windows and Imaging Selection (03.C.3) 19.3 Malignant Hemispheric Infarction and Basilar Artery Occlusion (03.C.1–2)
20 Intraparenchymal Hemorrhage
20.1 Intracerebral Hematoma (03.D.1) 20.2 Cerebellar Hematoma (03.D.2) 20.3 Intraventricular Hemorrhage (03.D.3)
21 SAH, CVST, and Spinal Cord Infarction
21.1 Aneurysmal Subarachnoid Hemorrhage (03.E.1) 21.2 Non-Aneurysmal SAH (03.E.2) 21.3 Cerebral Venous Sinus Thrombosis (03.F) 21.4 Spinal Cord Infarction (03.G)
22 Vascular Anomalies and Traumatic Brain Injury
22.1 Unruptured Aneurysm, Cavernoma, AVM, and Dural AVF (03.H) 22.2 Diffuse Axonal Injury and Cerebral Contusions (03.I.1–2) 22.3 Epidural Hematoma, Subdural Hematoma, and Penetrating Injury (03.I.3–4, 7) 22.4 Arterial Dissection and Carotid-Cavernous Fistula (03.I.5–6)
23 Spine, Hydrocephalus, and CNS Infection
23.1 Spinal Cord Injury, Central Cord, and Neurogenic Shock (03.J) 23.2 Unstable Spine Fractures (03.K) 23.3 Hydrocephalus and CSF Diversion (03.L) 23.4 Acute CNS Infections (03.M)
24 Seizures and Neuromuscular Emergencies
24.1 Status Epilepticus and Seizures (03.N) 24.2 Guillain-Barré Syndrome (03.O.1) 24.3 Myasthenic Crisis (03.O.2) 24.4 Motor Neuron Disease, Acute Myopathies, Rhabdomyolysis, and CINM (03.O.3–6)
25 Inflammatory Disease, Neuro-Oncology, and Special Populations
25.1 Fulminant Demyelinating Diseases (03.P) 25.2 Autoimmune Encephalitis and Acute Autonomic Hyperactivity (03.Q–R) 25.3 Neuro-Oncology and Treatment Complications (03.S) 25.4 Pregnancy/Post-Partum, Post-Transplant, and Pediatric Patients (03.T–U)
26 Neurosurgical and Perioperative Complications
26.1 Postoperative Seizures, Hemorrhage, Ischemia, and Hyperperfusion (04.A, C, D, H) 26.2 Infection, CSF Leak, and Pneumocephalus (04.B, E, F) 26.3 Complications of EVD and Lumbar Drain (04.G, I)
27 Ethics, Prognostication, and Organ Donation
27.1 Communication, Decision-Makers, Advance Directives, and DNR (05.A, B, G) 27.2 Uncertainties of Prognostication and the Self-Fulfilling Prophecy (05.C) 27.3 Palliative Care, Withdrawal, Withholding, and Futility (05.D–F) 27.4 Donation After Cardiac Death and Care of the Organ Donor (05.H–I)
25.4 Pregnancy/Post-Partum, Post-Transplant, and Pediatric Patients (03.T–U)
Key Takeaways Explain This Topic AI
Eclamptic seizures are treated with magnesium sulfate (typical load 4–6 g IV then 1–2 g/h), not a phenytoin-first status pathway; definitive therapy of severe preeclampsia, eclampsia, and HELLP is delivery after maternal stabilization.
Postpartum thunderclap headache, seizures, or visual change should trigger a differential of PRES, RCVS, and cerebral venous thrombosis, not only migraine; treat severe blood pressure (generally ≥160/110 mm Hg) with labetalol, hydralazine, or nifedipine.
Calcineurin inhibitors (tacrolimus, cyclosporine) cause PRES after organ transplant; opportunistic CNS infection and EBV-associated lymphoma or PTLD enter the same time window as immunosuppression intensity.
The 2023 AAN/AAP/CNS/SCCM BD/DNC guideline uses age-based rules: two independent examinations about 12 hours apart in children under 18 years, a minimum of one examination in adults, and no BD/DNC determination before 37 weeks postmenstrual age.
Internists sitting this shared exam still see pediatric items: weight-based dosing, abusive head trauma recognition, and neurologic injury on congenital-heart and ECMO circuits. ABIM and ABPN do not publish a separate pediatric percent-correct cut score for this 270-item examination.
Last updated: September 2026
Why special populations are written as one section
The content specifications group pregnancy and post-partum (03.T.1) , post-organ transplant (03.T.2) , and pediatric patients (03.U) . Intensivists whose primary training is internal medicine still encounter these stems on the shared computer-based examination that ABPN administers. Treat the physiology in front of you. Do not invent a unpublished pediatric passing percentage or a separate ABIM pediatric cut score—none is published for this 270-item exam.
Preeclampsia, eclampsia, and HELLP
Preeclampsia is new hypertension after 20 weeks of gestation plus proteinuria or end-organ involvement (platelets, creatinine, liver enzymes, pulmonary edema, or cerebral or visual symptoms). Severe-range blood pressure is commonly systolic ≥160 mm Hg or diastolic ≥110 mm Hg . Eclampsia is a seizure in that setting, including postpartum. HELLP is hemolysis, elevated liver enzymes, and low platelets; it can occur with or without massive proteinuria and is a delivery indication after stabilization.
Magnesium sulfate is first-line for eclamptic seizures and for seizure prophylaxis in preeclampsia with severe features. A typical intravenous regimen is a 4–6 g load over 15–20 minutes , then 1–2 g/h . If intravenous access is impossible, an intramuscular load of 10 g (5 g in each buttock) is the historic alternative. Recurrent seizures may receive an additional 2 g bolus. Watch for magnesium toxicity: loss of deep-tendon reflexes, then respiratory depression; calcium gluconate is the reversal. Adjust maintenance in renal failure.
This is not the ESETT pathway. Benzodiazepines may be used if the airway is lost or seizures continue despite magnesium, but the examination error is reaching for phenytoin or levetiracetam instead of magnesium in a clearly eclamptic patient. Magnesium is a poor antihypertensive; treat severe hypertension separately with intravenous labetalol, intravenous hydralazine, or oral nifedipine . Avoid ACE inhibitors in pregnancy.
Delivery planning is definitive therapy for eclampsia, HELLP, and preeclampsia with severe features once the mother is oxygenating, seizing less, and coagulopathy is addressed. Mode and timing are obstetric decisions; the neurointensivist’s job is airway protection during convulsions, left-uterine-displacement positioning, blood-pressure control without placental hypoperfusion, magnesium continuation typically 24 hours postpartum , and a plan for where the patient will seize if she seizes again. Fetal monitoring does not override maternal CPR mechanics.
PRES, RCVS, and cerebral venous thrombosis
The same puerperal week produces three overlapping cerebrovascular syndromes:
Syndrome Clue Imaging ICU treatment idea
PRES (posterior reversible encephalopathy syndrome) Seizures, visual change, hypertension; overlaps eclampsia Vasogenic edema, often posterior but can be atypical and hemorrhagic Blood-pressure control, magnesium if eclamptic, delivery as indicated
RCVS (reversible cerebral vasoconstriction syndrome) Recurrent thunderclap headache, postpartum, vasoconstrictive drugs Beading on angiography; convexity SAH possible Blood-pressure and trigger control; calcium-channel blockers are used; distinguish from vasculitis
CVT (cerebral venous thrombosis) Headache, seizures, hemorrhagic infarcts that cross arterial territories, postpartum hypercoagulability MR or CT venography Anticoagulation even with hemorrhage; treat seizures and intracranial hypertension
Do not send a postpartum thunderclap home as migraine. Do not start dual antiplatelet therapy for RCVS as if it were atherosclerotic stenting. CVT anticoagulation despite hemorrhage is the classic counterintuitive move already taught in the venous-stroke chapter; here the trigger is the puerperium.
Blood-pressure targets in eclampsia/PRES are treat severe-range hypertension while avoiding a sudden plunge that wipes out cerebral and placental perfusion. There is no single secret number that replaces treating ≥160/110 mm Hg and watching the neurologic exam.
Post-organ transplant
Three neurologic disaster clusters dominate the transplant ICU.
Calcineurin-inhibitor PRES. Tacrolimus and cyclosporine cause PRES, tremor, seizures, and sometimes atypical edema that is not strictly posterior. Check a drug level, but toxicity can occur in the “therapeutic” range. Reduce or switch the calcineurin inhibitor, control blood pressure, and treat seizures. Do not double the tacrolimus because the patient is “rejecting” when the MRI is PRES.
Opportunistic CNS infection. Timing follows immunosuppression: early bacterial surgical infection, then months of Aspergillus (stroke plus hemorrhage, ring lesions), Cryptococcus (high-pressure meningitis), Toxoplasma (ring-enhancing, especially after heart transplant or in patients off prophylaxis), Nocardia , Listeria , JC-virus PML , HHV-6 limbic encephalitis after hematopoietic transplant, and CMV. Steroids and more calcineurin inhibitor without an infection search is how these patients die. Send CSF, antigen tests, and MRI before you call every lesion PTLD.
Lymphoma and PTLD. Epstein–Barr virus–associated post-transplant lymphoproliferative disorder and primary CNS lymphoma present with mass lesions, leptomeningeal disease, or encephalitis. Treatment conceptually includes reducing immunosuppression , rituximab-based therapy, and high-dose methotrexate regimens in selected patients. Biopsy when safe; empiric steroids can again vanish lymphoma.
Graft-versus-host disease, PRES from other drugs (including VEGF blockade), and calcineurin-inhibitor thrombotic microangiopathy round out the differential. The stem’s timeline and drug list matter more than a rare eponym.
Pediatric patients on a predominantly adult exam
You will see pediatric stems. The shared examination covers pediatric patients (03.U) even when your diploma says internal medicine. What you will not see is a published, pediatric-only percent-correct cut score for ABIM candidates. Scoring is a criterion-referenced total standard score on the 270-item test; do not memorize a fake pediatric passing percentage.
Age-based brain death / death by neurologic criteria (BD/DNC). The 2023 AAN/AAP/CNS/SCCM consensus guideline unifies pediatric and adult determination with age-specific rules:
Do not determine BD/DNC before 37 weeks postmenstrual age .
In children younger than 18 years , two attending clinicians perform independent examinations , with an observation interval of 12 hours for all pediatric ages in the 2023 document (replacing the older 24-hour/12-hour age split).
In adults , a minimum of one examination is required; a second examiner may be added.
Pediatric blood-pressure prerequisites use SBP and MAP at least the 5th percentile for age , not the adult 100/75 mm Hg pair alone.
Two apnea tests are described for children versus one in adults in summaries of the 2023 pathway; ancillary testing is used when the examination or apnea test cannot be completed.
Full prerequisites, the apnea carbon dioxide rule (PaCO2 ≥60 mm Hg and ≥20 mm Hg above baseline), and ancillary-test details live in the brain-death chapter. Here the point is: children are not small adults on the observation clock.
Different dosing. Pediatric infusions, osmotic agents, antiseizure loads, and sedation are weight-based , with age-specific hemodynamics and a smaller margin for propofol-infusion syndrome in children. Do not copy an adult 4 mg lorazepam cap onto a 12 kg toddler, and do not invent an official exam “pediatric dose table” that ABPN did not publish. Use known pediatric emergency doses when a stem gives a weight.
Abusive head trauma (AHT). Recognize the mismatch: a trivial history, an infant with subdural hemorrhage , retinal hemorrhages , and encephalopathy, plus additional injuries (posterior rib fractures, metaphyseal lesions, bruising). The triad is not pathognomonic —glutaric aciduria, coagulopathy, and accidental trauma remain on the list—but the ICU obligation is to protect the child , document, involve child protection, obtain a skeletal survey and dilated retinal exam, and avoid contaminating the history with leading questions. Hypoxic-ischemic injury on MRI is common in severe AHT and does not by itself equal a natural SIDS death.
Congenital heart disease and ECMO. Neonatal and infant heart surgery and extracorporeal membrane oxygenation (ECMO) produce stroke, intracranial hemorrhage on anticoagulation, seizures, white-matter injury, and cannulation-related carotid complications on VA ECMO. Deep hypothermic circulatory arrest historically associated with choreoathetosis. The internist-neurointensivist may be asked to manage anticoagulation-related ICH, EEG monitoring, or BD/DNC on ECMO (specialized apnea and ancillary rules). Anticipate neurologic injury rather than assuming a perfect circuit means a perfect brain.
Examination traps
Phenytoin-first for a 32-week eclamptic seizure.
Ignoring postpartum thunderclap because delivery is over.
Raising tacrolimus in PRES.
Declaring pediatric brain death with a single adult-style examination at 36 weeks postmenstrual age.
Inventing a pediatric passing score.
Dismissing AHT because the caregiver’s story is confident.